Missouri Nurse Leaders Stand Up for APRNs, Health Care Consumers

Freeing up advanced practice registered nurses to provide unrestricted care is just one of the many priorities on the Missouri Action Coalition's agenda.

When a massive tornado struck Joplin, Mo., last spring, advanced practice registered nurses (APRNs) were standing by to help the town’s survivors recover. But unfortunately, that’s all they could do; state regulations barred them from providing the full range of care needed in the aftermath of the storm, according to Jill Kliethermes, MSN, RN, FNP-BC, chief executive officer of the Missouri Nurses Association.

“APRNs were not able to see patients and provide prescriptions for necessary medications in the wake of the tornado,” she says. “They should have been allowed to serve to the full extent of their training and abilities, especially in an emergency situation like that one.”

A band of nurse leaders is teaming up to change those rules so that the next time disaster strikes, patients have full access to care from all available providers.

The nurses are pushing state legislation that would remove barriers that prevent the state’s APRNs from practicing to the full extent of their training and abilities. The bill would, for example, remove requirements that APRNs practice within a certain distance of a physician collaborator; that physicians review an APRN’s medical charts on a frequent and regular basis; and that they sign off on a certain percentage of patients who have receive controlled substances from APRNs.

“We are asking to be allowed to practice to the full extent of our education, as is the case in many other states,” Kliethermes says.

The bill is currently moving its way through the state legislature. If Kliethermes and her allies prevail, it would be a major victory for nurses and the patients they serve, she says. It would open up access to care in a state that—in spite of a shortage of primary care providers—places some of the tightest restrictions in the country on APRNs.

Primary care providers are indeed desperately needed in Missouri, a largely rural state where many residents lack access to care. Nearly all of the counties in Missouri, in fact, have been designated as areas where residents are either medically underserved or have limited access to health care professionals, according to a report published by the Missouri Nurses Association.

The shortage of primary care providers in the state threatens to worsen in 2014, when hundreds of thousands of patients will have new access to health care under the federal health reform law enacted in 2010. Compounding the problem is the fact that Missouri’s population—and its population of physicians—is aging, and fewer medical students are choosing to enter primary care, according to the Missouri Nurses Association report.

Allowing APRNs to practice to their full scope only makes sense, Kliethermes says. “There is not going to be a shortage of patients to be seen; however we are going to have a huge shortage of providers in 2014—in fact, we already do, and it’s going to get a lot worse. We are going to have to figure this out. The time is now.”

But even if the scope-of-practice bill stalls this year, advocates have made major progress. Thanks to their work, it has moved farther this year than ever before—earning sponsors in the state House and Senate and taking the spotlight at legislative hearings.

One of Many Priorities

Nurse leaders pushing the bill are working under the auspices of a group known as the Missouri Action Coalition, which brings together nurses with diverse leaders from other sectors. Like its counterparts in 47 other states, the Missouri Action Coalition is advancing recommendations from a report released in 2010 by the Institute of Medicine (IOM). Called The Future of Nursing: Leading Change, Advancing Health, itlays out a strategy to ensure that all Americans have access to high-quality, patient-centered care in a health care system where nurses contribute as essential partners.

Action Coalitions are a driving force behind the Future of Nursing: Campaign for Action, a collaborative effort of AARP, the AARP Foundation and the Robert Wood Johnson Foundation (RWJF) to implement solutions to the challenges facing the nursing profession and to build upon nurse-based approaches to improving quality and transforming the way Americans receive health care.

Advancing the scope-of-practice bill in Missouri is just one of the many activities undertaken this past year by the Action Coalition, which is led by the Missouri Nurses Association, the Missouri League of Nursing, and the Missouri Health Advocacy Alliance.

The group has its roots in a summit on nursing education advancement that took place in Jefferson City, Mo., shortly after the IOM report on the future of nursing was released. Out of that meeting grew a group committed to implementing the report’s recommendations in the state. Kliethermes and other leaders organized a teamwork summit in June 2011, which was attended by more than 230 supporters.

At the summit, participants separated into four teams that focused on the following areas: education, practice, leadership, and the nursing workplace and workforce. Since then, the teams have identified priorities and action items and met via conference calls and webinars. They are planning to gather at a second summit on June 6th and 7th.

The group was recognized as an official Action Coalition in September; it is led by a 10-member executive committee and a 30-member strategic advisory team.

There has been a lot of discussion along the way, especially about the IOM report goal to have 80 percent of registered nurses be BSN prepared by 2020, Kliethermes says. Associate-degree nurse educators, she notes, have expressed concern that requiring bachelor’s degrees in nursing could narrow access to education for aspiring nurses, especially those in rural areas or those with lower-incomes. Generating resources, engaging supporters and attracting non-nurse leaders have also been challenges, Kliethermes adds.

Still, Missouri Action Coalition members take pride in their accomplishments so far. In addition to pushing scope-of-practice legislation forward, they have taken steps to make it easier for associate degree-prepared nurses to move into baccalaureate programs through a seamless articulation agreement and are working to establish a state nursing workforce center to collect nursing data.

Meanwhile, the Missouri Action Coalition received a $40,000 grant from the Health Care Foundation of Kansas City. And prominent nurse leaders, such as Linda Aiken, PhD, RN, FAAN, a nurse researcher who directs the Center for Health Outcomes and Policy Research at the University of Pennsylvania, have signed up to address participants at the second Missouri Action Coalition summit this coming June.

“Thanks to many volunteers, we have made remarkable progress with so few resources,” Kliethermes says.